Healthcare Provider Details

I. General information

NPI: 1982330205
Provider Name (Legal Business Name): VICKIE LYNN ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKIE LYNN LEADINGHAM

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 FARRELL DR
COVINGTON KY
41011-3717
US

IV. Provider business mailing address

607 BRANDTLY RIDGE DR
COVINGTON KY
41015-4227
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-3200
  • Fax:
Mailing address:
  • Phone: 859-322-6845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: